Nationwide New Heights™ Annuity Withdrawal Form Nationwide’ Nationwide Life Insurance Company Nationwide Life and Annuity Insurance Company ‘Skip the paperwork: Complete this form electronically at nationwide.com for quicker handling Contact Us: For questions about this form call 800-848-6331 1. Enter Contract Owner Information First Name: Elizabeth Last Name: Chuakay ‘Contract Number: 070479813 ‘Address: 863 E. Angela St if City: Pleasanton state: CA Zip; 94566 Phone: (925) 321-2430 Email; bchuakay@sboglabal.net [Nationwide strives to provide excellent customer service to our Members. By providing your telephone number, you authorize the "Nationwide Family of Companies to contact you via telephone using automated technology to assist you with your account. 2. Select Transaction Type IMPORTANT: Don't use this form with Nationwide High Point 365% lifetime income withdrawals. Choose one option: © One-Time withdrawal (Skip to Section 3) 1 Setup RMD/Recurring Withdrawal (Default) Choosing this option will terminate any existing Scheduled Withdrawals, including RMDs Set up new Recurring Withdrawal (Skip to Section 4) Set up new Required Minimum Distribution (RMD) (Skip to Section 5) (Replace or Change Existing RMD/Recurring Withdrawal Update Existing Recurring Withdrawal (Skip to Section 4) Update Required Minimum Distribution (RMD) (Skip to Section 5) 1 Terminate All Ex 1g RMD/Recurring Withdrawal(s) (Complete sections 1, 2 and 8 only) IMPORTANT: You may not meet IRS withdrawal requirements If you change or terminate your RMD. It's your responsiblity to meet RMD requirements. 3. Request a One Time Withdrawal Be sure to review the Important Details and Disclosures beginning on Page 5 before making an election. C1 Specific amount: $ Ci Gross withdrawal (Default) Before taxes (you select below), charges, MVA and/or bonus adjustments Di Cash withdrawal ‘The amount paid to you by check or direct deposit. Equal to the Gross Withdrawal minus taxes, any Contingent Deferred Sales Charge (CDSC), MVA and/or recoupment of unvested Purchase Payment Bonus, if applicable. © Free withdrawal: (New form required annually) Maximum withdrawal amount available without CDSC, MVA and/or recoupment of unvested bonus, if applicable. Full Withdrawal/Contract Surrender NEXT: Skip to Section 6 FAFF-0009A0.8 Page 1of 6 (08/2021)4, Request a Recurring Withdrawal Be sure to review the Important Detalls and Disclosures beginning on Page 5 before making an election. Gi Specific amount: $ 0 Gross withdrawal (Default) Before taxes (you select below), charges, MVA and/or bonus adjustments T Cash withdrawal The amount paid to you by check or direct deposit. Equal to the Gross Withdrawal minus taxes, any CDSC, MVA and/or recoupment of unvested Purchase Payment Bonus, if applicable. (Free Withdrawal: (New form required annually) ‘Maximum withdrawal amount available without CSC, MVA and/or recoupment of unvested bonus, Entera Start Date; MM/DD/YY) applicable, Gf blank, or the requested date has passed, we'll default to current business day) Select a Withdrawal Frequency (if left blank, we'll default to Monthly) Cl Annually £] Semi-Annually [] Quarterly 1] Monthly NEXT: Skip to Section 6 5. Request Required Minimum Distribution IMPORTANT: This section is applicable for IRA, 403(b) and 401 contracts when the contract owner(s) has reached 70% years (if date of birth is before July 1, 1949) or 72 years (If date of birth is on or after July 1, 1949.) Don't use this form with Nationwide Hight Point 365% lifetime income withdrawals. Be sure to review the Important Detalls and Disclosures beginning on Page 5 before making an election. Don't use this form with Nationwide Hight Point 365% lifetime income withdrawals. ‘Select ONE Scheduled RMD Option below Recurring Option (calculated by Nationwide) Enter start date and frequency below: Start Date (MM/DD/YYYY): at Select a withdrawal frequency (if eft blank, we'll default to Annually): CD Annually C] semi-annually [] Quarterly [] Monthly Cone Time Option (new request form required annually) Enter start date and choose option below: Withdrawal Date (MM/DDy: Done time current year only (calculated by Nationwide) Ci Current year specific amount §, Past year specific amount $. ______ for RMD year: RMD Spousal Beneficiary Election Di My spouse is my beneficiary and is 1! or more years younger than | am. | elect to calculate my RMD based on the Joint and Last Survivor Expectancy Table method. My spouse's date of birth is: (MM/DD/YYYY) Prior Year Account Balance Required for Nationwide to calculate your RMD if you purchased or added to your annuity this year with funds from another provider. The 12/31 account balance with my previous provider was $. 403(b) balance as of 12/31/1986 $_________ Gif applicable) FAFF-O009A0.8, Page 2 of 6 (05/2020)6. Enter Tax Withholdings Nationwide will withhold 10% federal tax and any required Re: federal and state tax withholding cannot exceed 100%. font State tax, unless designated differently below. Total Federal Tax Withholding 20.00% or §. (0% -100%) ‘State Tax Withholding 2.00% or §. (0% - 100%) + Qualified plans subject to 20% mandatory federal withholding. See Important Detailsand Disclosures for more information, + To avoid mandatory state withholding, for those states that require it, you MUST provide a completed state tax form located on the State's website). Nationwide does not provide these forms, 7. Select a Payment Method © Direct Deposit You are authorizing a one-time or recurring Automated Clearing House (ACH) credit (direct deposit) to the bank account provided on this form. Funds must be deposited to a U'S. Institution. Select an account type’: Account on File Verify account information below © New Checking Account? Provide account information below (New Savings Account? Provide account information below 1If there is no account on file, or you don’t provide account information, we'll mail a check to the address on file. 2New account information will replace account information on file for this contract, This will affect any other existing scheduled withdrawals. Call 800-848-6331 to make other arrangements. Bank Account Holder Name (must be Contract Owner): Elizabeth Chuakay Financial Institution Name: JP MORGAN CHASE BANK Transit/ABA Routing Number: 322271627 ‘Account Number: 2611392907 1 Mall Check to Address on File C1 Send to my Custodial Account (My contract has a custodial firm as owner; Nationwide will issue funds per agreement) C0 Send to a Company/Organiz. n/Charity For Benefit of (FBO) - Provide information below Check payable to/Name’ asl Address: City: State: Zip: FAFF-O009A0.8 Page 3 of 6 (05/202)8. Sign and Date (required) | have read the Important Details and Disclosures beginning on Page 5. | certify that all of the information | have provided in this form is accurate and true. ‘The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avold backup withholding. ‘Owner/Custodia Name (please print): Elgabeth Chuakay SSN/TIN (required): 06-26-5642 Signature Date: 10/25/2021 Joint Owner (it applicable Name (please print): Signature: = Date: ‘Spousal Consent (it applicable; see the Community Property Spousal Consent section on page 6 to determine applicability): have read and understand the community property disclosure found on this form. | agree that this disclosure applies to me and | consent to the distribution requested and waive any rights that | may have to such Annuity Contract under applicable community property laws. Signature: Date: 9. Certify Taxpayer ID | certify that under penalties of perjury that: 1. The Taxpayer Identification Number or Social Security Number listed on this form is my correct taxpayer identification umber (or | am waiting for a number to be issued to me), and 2. 1am not subject to backup withholding because: 2. am exempt from backup withholding, or »b, | have not been notified that | am subject to backup withholding as a result of a failure to report all interest or dividends, or . The Internal Revenue Service has notified me that | am no longer subject to backup withholding, and 3. lama US. citizen or other US. person, and 4, The FATCA code(s) entered on this form (if any) indicating that | am exempt from FATCA reporting is correct. (FATCA does not apply as this is a U.S. account) You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding because of failure to report interest or dividends on your tax return. 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